Snapshot As a dermatology resident, you are studying cutaneous manifestations of viral diseases. You come across a photo of a child with hundreds of pustular lesions, primarily on the face but also affecting the mucosa and the rest of the body. You realize that this was a disease resulting from a virus that is similar to the one causing chickenpox; however, it has been eradicated with global vaccination. Introduction Classification variola a poxvirus an enveloped, linear, double-stranded DNA virus Epidemiology incidence the disease has been eradicated with global vaccination risk factors bioterrorism Pathogenesis patients remain contagious until the lesion scabs and all scabs fall off naturally Associated conditions smallpox Prevention live-attenuated vaccine Prognosis mortality was very high with an overall fatality of 30% Presentation Symptoms initial prodrome fever and chills headache spinal pain pharyngitis may have a fine macular rash characteristic rash occurs after prodrome Physical exam characteristic rash has 3 phases and is synchronous (i.e., all lesions are at the same stage of development) initial small, red, non-blanching macules develops into firm papules then into pustules and larger vesicles with central umbilication affects both mucosa and skin but is denser on the face lesions develop a scab by the second week conjunctivitis Studies Labs polymerase chain reaction assay Electron microscopy brick-shaped virions with internal dumbbell-shaped core containing viral DNA from vesicular or pustular fluid Making the diagnosis based on clinical presentation Differential Varicella (chicken pox) distinguishing factors typically does not have a prodromal phase and begins with an exanthematous rash progression from initial rash to scab is 7 days (vs 14 days in variola) Treatment Management approach mainstay treatment is supportive care patients should be isolated Conservative supportive care indication all patients modalities intravenous fluids analgesics good wound care Complications Cutaneous scarring Encephalitis Stillbirth